§ 36-6908. Group or individual contract - Delivery - Required provisions - Evidence of coverage - Filing and review of forms.

A.  1.  Every group and individual contract holder is entitled to a group or individual contract which may be delivered through electronic means or methods; provided, a member has given written assurances to the health maintenance organization that the member can view and print such electronic copy.

2.  The contract shall not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by Articles 12 and 12A-1 of the Insurance Code.

3.  The contract shall contain a clear statement of the following:

a.the name and address of the health maintenance organization,

b.eligibility requirements,

c.benefits and services within the service area,

d.emergency care benefits and services,

e.out of area benefits and services, if any,

f.copayments, deductibles or other out-of-pocket expenses,

g.limitations and exclusions,

h.enrollee termination,

i.enrollee reinstatement, if any,

j.claims procedures,

k.enrollee grievance procedures,

l.continuation of coverage,

m.conversion,

n.extension of benefits, if any,

o.coordination of benefits, if applicable,

p.subrogation, if any,

q.description of the service area,

r.entire contract provision,

s.term of coverage,

t.cancellation of group or individual contract holder,

u.renewal,

v.reinstatement of group or individual contract holder, if any,

w.grace period, and

x.conformity with state law.

An evidence of coverage may be filed as part of the group contract to describe the provisions required in this paragraph.

B.  In addition to those provisions required in paragraph 3 of subsection A of this section, an individual contract shall provide for a ten-day period to examine and return the contract and to refund any premiums.  If services were received during the ten-day period, and the subscriber returns the contract to receive a refund of the premium paid, he or she must pay for those services.

C.  1.  Every subscriber shall receive an evidence of coverage from the group contract holder or the health maintenance organization.

2.  The evidence of coverage shall not contain provisions or statements that are unfair, unjust, inequitable, misleading, deceptive, or that encourage misrepresentation as defined by Articles 12 and 12A-1 of the Insurance Code.

3.  The evidence of coverage shall contain a clear statement of the provisions required in paragraph 3 of subsection A of this section.

D.  Every health maintenance organization doing business in this state shall comply with the provisions of Article 36A of the Insurance Code.

E.  No group or individual contract, evidence of coverage or amendment thereto, shall be delivered or issued for delivery in this state, unless its form has been filed with and approved by the Insurance Commissioner, subject to the provisions of subsections F and G of this section.

F.  If an evidence of coverage issued pursuant to and incorporated in a contract issued in this state is intended for delivery in another state and the evidence of coverage has been approved for use in the state in which it is to be delivered, the evidence of coverage need not be submitted to the Insurance Commissioner of this state for approval.

G.  1.  Every form required by this section shall be filed with the Insurance Commissioner not less than thirty (30) days prior to delivery or issue for delivery in this state.  At any time during the initial thirty-day period, the Insurance Commissioner may extend the period for review an additional thirty (30) days.  Notice of an extension shall be in writing.  At the end of the review period, the form is deemed approved if the Insurance Commissioner has taken no action.  The filer must notify the Insurance Commissioner in writing prior to using a form that is deemed approved.

2.  At any time, after thirty (30) days’ notice and for cause shown, the Insurance Commissioner may withdraw approval of a form, effective at the end of the thirty (30) days.

3.  When a filing is disapproved or approval of a form is withdrawn, the Insurance Commissioner shall give the health maintenance organization written notice of the reasons for disapproval and in the notice shall inform the health maintenance organization that within thirty (30) days of receipt of the notice the health maintenance organization may request a hearing.  A hearing shall be conducted within thirty (30) days after the Insurance Commissioner has received the request for hearing.

H.  The Insurance Commissioner may require the submission of relevant information he or she deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.

Added by Laws 2003, c. 197, § 9, eff. Nov. 1, 2003.